2017-06-19_REPORT - M1978192

• Permit No: M1978192
• IBM Index Class Name: REPORT
• Doc Date: 6/19/2017
• Doc Name: Annual Fee/Report/Map
• From: Chaffee County
• To: DRMS
• Annual Report Year: 2017
• Email Name: DMC
• Media Type: D
• Archive: No

Page 5 of 5
Division records indicate the following permittee/landowner contact information(blank fields indicate that we do not have
information on record). If this information is blank or not current,please type or print current contact information:
Permittee Contact: Mark Stacy
Permittee Company: Chaffee County
Address: P.O. Box 699
Salida, CO 81201
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Permitting Contact: Mark Stacy
Company: Chaffee County
Address: P.O. Box 699
Salida, CO 81201
Phone Number: [phone]
Fax Number: [phone]
Email Address:
Inspection Contact: Joe Nelson MA ,o
Company: Chaffee County
Address: P.O.Box 699
Salida,CO 81201
Phone Number: [phone]
Fax Number: [phone]
Email Address:
I,the undersigned,hereby state that the information provided in this report is true and accurate,and that site operations are
being conducted in accordance with the Division approved mining and reclamation plans.
Signat e o mitt or orate Officer,Owner,or Documented Desianee Date
M-AF-04